Author + information
- Received August 6, 2018
- Revision received January 24, 2019
- Accepted January 28, 2019
- Published online April 15, 2019.
- Abdulla A. Damluji, MD, MPHa,b,∗ (, )@DrDamluji,
- Karen Bandeen-Roche, PhDc,
- Carol Berkower, PhDa,
- Cynthia M. Boyd, MD, MPHd,
- Mohammed S. Al-Damluji, MD, MPHe,
- Mauricio G. Cohen, MDf,
- Daniel E. Forman, MDg,h,
- Rahul Chaudhary, MDa,
- Gary Gerstenblith, MDb,
- Jeremy D. Walston, MDd,
- Jon R. Resar, MDb and
- Mauro Moscucci, MD, MBAa,i,∗∗ (, )@MMoscucci
- aSinai Hospital of Baltimore, LifeBridge Health Cardiovascular Institute, Baltimore, Maryland
- bDivision of Cardiology, Johns Hopkins University, Baltimore, Maryland
- cDepartment of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- dDivision of Geriatric Medicine and Gerontology, Johns Hopkins University, Baltimore, Maryland
- eDepartment of Internal Medicine, University of Connecticut Health Center, Farmington, Connecticut
- fCardiovascular Division, University of Miami, Miami, Florida
- gGeriatric Cardiology Section, University of Pittsburgh, Pittsburgh, Pennsylvania
- hGeriatric Research, Education, and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- iUniversity of Michigan Health System, Ann Arbor, Michigan
- ↵∗Address for correspondence:
Dr. Abdulla A. Damluji, Johns Hopkins University School of Medicine, 2435 West Belvedere Avenue, Suite 32, Baltimore, Maryland 21215.
- ↵∗∗Dr. Mauro Moscucci, Department of Medicine, Sinai Hospital of Baltimore, University of Michigan Health System, 2435 West Belvedere Avenue, Suite 32, Baltimore, Maryland 21215.
Background Older adults ≥75 years of age carry an increased risk of mortality after ST-segment elevation myocardial infarction (STEMI) complicated by cardiogenic shock.
Objectives The purpose of this study was to examine the use of percutaneous coronary intervention (PCI) in older adults with STEMI and shock and its influence on in-hospital mortality.
Methods We used a large publicly available all-payer inpatient health care database sponsored by the Agency for Healthcare Research and Quality between 1999 and 2013. The primary outcome was in-hospital mortality. The influence of PCI on in-hospital mortality was assessed by quintiles of propensity score (PS).
Results Of the 317,728 encounters with STEMI and shock in the United States, 111,901 (35%) were adults age ≥75 years. Of these, 53% were women and 83% were Caucasians. The median number of chronic conditions was 8 (interquartile range: 6 to 10). The diagnosis of STEMI and cardiogenic shock in older patients decreased significantly over time (proportion of older adults with STEMI and shock: 1999: 42% vs. 2013: 29%). Concomitantly, the rate of PCI utilization in older adults increased (1999: 27% vs. 2013: 56%, p < 0.001), with declining in-hospital mortality rates (1999: 64% vs. 2013: 46%; p < 0.001). Utilizing PS matching methods, PCI was associated with a lower risk of in-hospital mortality across quintiles of propensity score (Mantel-Haenszel odds ratio: 0.48; 95% confidence interval [CI]: 0.45 to 0.51). This reduction in hospital mortality risk was seen across the 4 different U.S. census bureau regions (adjusted odds ratio: Northeast: 0.41; 95% CI: 0.36 to 0.47; Midwest: 0.49; 95% CI: 0.42 to 0.57; South: 0.51; 95% CI: 0.46 to 0.56; West: 0.46; 95% CI: 0.41 to 0.53).
Conclusions This large and contemporary analysis shows that utilization of PCI in older adults with STEMI and cardiogenic shock is increasing and paralleled by a substantial reduction in mortality. Although clinical judgment is critical, older adults should not be excluded from early revascularization based on age in the absence of absolute contraindications.
- cardiogenic shock
- older adults
- percutaneous coronary intervention
- ST-segment elevation myocardial infarction
This study was funded in part by a research grant from the Jane and Stanley F. Rodbell family in support of geriatric cardiology research at Sinai Hospital of Baltimore. Dr. Damluji has received research funding from the Pepper Scholars Program of the Johns Hopkins University Claude D. Pepper Older Americans Independence Center (OAIC), funded by the National Institute on Aging (NIA) (P30-AG021334). Drs. Bandeen-Roche and Walston are coprincipal investigators of the OAIC; and they are supported by funding from the NIA (P30-AG021334). Dr. Boyd has received royalties for a chapter on multimorbidity from UptoDate. Dr. Cohen has served as a consultant for Medtronic. Dr. Resar has served on the Physician Advisory Board for Boston Scientific; and has received research grants from Medtronic, Abbott Vascular, and CSI. Dr. Moscucci has received book royalties from Wolters Kluwer and Lippincott Williams & Wilkins; and has stock ownership in Gilead Sciences. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. This work is part of a PhD thesis for Dr. Damluji at Johns Hopkins University’ GTPCI program. It was presented as an oral presentation at the American College of Cardiology (Geriatric Cardiology Section) 66th Annual Scientific Session, Washington, DC. The study received best clinical research award at the National Claude D. Pepper Older Americans Independence Centers funded by the NIA, National Institutes of Health.
Listen to this manuscript's audio summary by Editor-in-Chief Dr. Valentin Fuster on JACC.org.
- Received August 6, 2018.
- Revision received January 24, 2019.
- Accepted January 28, 2019.
- 2019 American College of Cardiology Foundation